MedRapid Medical Online Knowledge Reference with Integrated Quality Management E. Finkeissen, H. Fuchs, T. Jakob, T. Wetter Institute for Medical Biometry and Informatics Department of Medical Informatics, University of Heidelberg Im Neuenheimer Feld 400, 69120 Heidelberg, Germany Abstract Objective: currently, it takes at least 6 months for researchers to communicate their results. This delay is caused (a) by partial lacks of machine support for both representation as well as communication and (b) by media breaks during the communication process. Methods: To make an integrated communication between researchers and practitioners possible, a general structure for medical content representation has been set up. The procedure for data entry and quality management has been generalized and implemented in a web-based authoring system. Results: The MedRapid-system 1 supports the medical experts in entering their knowledge into a database. Here, the level of detail is still below that of current medical guidelines representation. However, the symmetric structure for an area-wide medical knowledge representation is highly retrievable and thus can quickly be communicated into daily routine for the improvement of the treatment quality. In addition, other sources like journal articles and medical guidelines can be references within the MedRapidsystem and thus be communicated into daily routine. Conclusions: The fundamental system for the representation of medical reference knowledge (from reference works/books) itself is not sufficient for the friction-less communication amongst medical staff. Rather, the process of (a) representing medical knowledge, (b) refereeing the represented knowledge, (c) communicating the represented knowledge, and (d) retrieving the represented knowledge has to be unified. MedRapid will soon support the whole process on one server system. Keywords: Community Medicine; Community Network; Community Health Aides; Information Management Systems. 1 http://www.medrapid.de
GENERAL WAYS OF MEDICAL KNOWLEDGE COMMUNICATION Problems with the current situation Most of the medical practitioners have to cope with an information overload [1]: A reference work/book can have only one point presentation and hence one type of access to the medical knowledge [2-4]. Moreover, a sequential presentation of the knowledge is required [4]. The separate formulation of the content of a book by several authors is even complicated by the differing usage of terminology [5]. Summarizing the discussion, it can hardly be controlled with standard methods, whether all important content has been mentioned; the knowledge of the reference work/book represents the state-of-the-art of research; the presented knowledge contains contradictions; a unified terminology is used; the same facts are multiple described. Moreover, most of the medical decision support systems (MDSS) are limited to partial aspects of medicine and therefore do not cover the full range of information needed in daily medical routine [6]. In the following, the interaction between the roles participating the communication of medical knowledge will be analyzed. From these results, the visions and aims as well as the external and internal communication paths of a unified communication platform will be derived. Generalizing the interaction between medical roles In both education and daily routine medical reference knowledge is mainly communicated by journals, reference works/books, and guidelines. This kind of communication is time consuming and lacks a comprehensive paradigm for both knowledge authoring and knowledge communication. For that reason, a general scheme has been developed for organizing the process of (a) acquisition (b) quality management and (c) distribution of medical knowledge (cf. figure 1). practinioners 5 6 Content critics, supplements authors 4 3 Entry struktural overviews Communication Medium Content critics, ratification 7 8 organizations feedback from system and users rights and obligations 2 1 editors Figure 1: General scheme for the processes of (a) acquisition, (b) quality management and (c) distribution of medical knowledge.
A general view to the interaction of the participating roles can be given (cf. figure 1): editors taking control over the rights and obligations during the knowledge acquisition process coordinate the content management. The authors can submit their knowledge and reviewers make comments from their viewpoint. In the MedRapid-system the reviewers are so called co-authors because they can suggest alternative formulations and add knowledge to the current proposal of the main author. Only if both author and co-authors agree upon a partial medical aspect it will be included into the knowledge base. Nevertheless, it has to be emphasized that the main author is the only person allowed to apply changes to the respective content. MEDICAL COMMUNITY & BUSINESS INTELLIGENCE MANAGEMENT MedRapid will soon offer a general platform for the representation and communication of medical textbook knowledge. The main emphasize lies on the supply of broad medical knowledge with nearly equivalent granularity and depth. Visions and aims for the MedRapid-service A general structure for medical reference knowledge representation had to be found. The general scheme has been implemented for the representation of the consensus between medical experts [7]. To make a representation of all medical aspects in a unified structure possible the information depth had to be limited. In routine, the practitioner not necessarily needs all details. E.g., procedural aspects of therapy only play a role when the practitioner has clarified the diagnoses and concentrated on the treatment planning. Such information can later be provided on demand. A main point is the up-to-datedness of the knowledge represented. With other words, an ubiquitous availability of both the authoring system and the resulting encyclopedia is important. Like this, the expert (author) and the practitioner (user) can communicate where ever they want or need to. To be able to cope with such a complex distributed system a superposed community management is required for the automated interaction between authors, editors, and practitioners. Here, suggestions and criticisms should concretely be related to the specific medical problem for the machine could find out all authors affected by a proposed change in content. A consensus has been found as soon as all affected authors (or co-authors) agree upon a fact from their point of view. Such an approach can be seen as a machine supported quality management. From this general visions the aims of MedRapid can be derived: Highly structured representation of the medical content; Authoring tools with integrated quality management; Referencing of further sources; Intelligent retrieval system. Internal knowledge representation As mentioned above, most of the content in MedRapid is represented formally. Here, a multi-axial concept system has been set up to form the fundamental terminology. These concepts should be used by the authors to represent their domain knowledge. The whole knowledge base is stored in a databank to make a fast retrieval possible. The concept system has been set up by the partitioning of the medical problem space into distinct aspects. To each partial aspect, a controlled vocabulary has been assigned. Each partial terminology can be revised or extended by the authors. Currently, the vocabularies are extended so the authors do not have to start the knowledge entry from
scratch. Similarly to the content, each terminological change has to be verified by the coauthors. Authoring The information entry will mainly be managed via a standard Internet-browser so the authors are not restricted to a specific place for knowledge entry. Here, an SHTMLconnection guarantees that the transmitted data cannot be scanned by others. Hence, the privacy of the authoring community is guaranteed. Figure 2: Terminological search engine of the MedRapid system. During the process of knowledge entry, appropriate concepts have to be found for the proper interpretation of the knowledge by the machine. Here, an internal search engine supports the navigation within the concept systems. Multiple controlled vocabularies are used for specific partial medical aspects. Because of the size of some of the concept systems, the search engine helps navigating through the lists (cf. figure 2). The hierarchical ordering provides a structural access to the required term. The search string is highlighted so the user can easily distinguish interesting response from the others. External communication of the main system A subsystem for multi-media will store picture, video sequences, sound, etc. the authors want to provide. Via interfaces information from external services like journals, electronic patient records, etc. will be connected (cf. figure 3).
clients (external) server (internal) servers (external) WWW interface multi-media applications elektronic patient record Java applet Internet medical main system external interfaces Internet Medline (journals)... concept of rights... Figure 3: The main system supports authoring, storage and retrieval of medical knowledge. Via interfaces, external services can be integrated transparently into the client application. SUMMARY AND PROSPECTS The structure for the representation of the medical content has been set up within MedRapid. An authoring system has been integrated. The automated community management has been tested. External sources can already be referenced within the system. Presently, the search engine for the practitioners retrieval is optimized. With the help of MedRapid, the time and effort for authoring and the retrieval of knowledge can be reduced. A quality improvement by the system is expected due to the enhancement of the interaction amongst medical experts and practitioners. In the near future, the content of the system will be expanded from few test areas to multiple medical disciplines. Soon, the MedRapid-structure can be used by external services for the referencing of other information like in guidelines, literature, multimedia, films, and pictures. Since most of the content in the MedRapid-system is represented formally, both the input (authoring) and the output (retrieval) with the MedRapid-system can soon be translated into several languages based e.g. on UMLS. References 1. Zeng Q, Cimino J. A Knowledge-Based, Concept-Oriented View Generation System for Clinical Data. Journal of Biomedical Informatics 2001; 34:112-128. 2. Bethke K, Kunzer W, Schaub J. Computer in der Ärzteausbildung. München: Oldenburg; 1990. 3. Gross R, Schölmerich P, Gerok W. Die Innere Medizin. Stuttgart: Schattauer; 1994. 4. Knaup P. Rechnergestützte Erstellung medizinischer Lehrbücher unter Verwendung formal repräsentierten Wissens. Heidelberg: Ruprecht-Karls-Universität Heidelberg; 1994. 5. Bürkle T. Can we classify Medical Data Dictionaries? In: Hasman A, Blobel B, Dudeck J, Engelbrecht R, Gell G, Prokosch H-U, Medical Infobahn for Europe. Amsterdam: IOS Press; 2000. 6. Wendt T, Knaup-Gregori P, Winter A. Decision Support in Medicine: A Survey of Problems of User Acceptance. In: Hasman A, Blobel B, Dudeck J, Engelbrecht R, Gell G, Prokosch H-U, Medical Infobahn for Europe. Amsterdam: IOS Press; 2000. 7. Finkeissen E. Notwendigkeit und Grenzen eines Referenzservers zur Repräsentation eines medizinischen Entscheidungsstandards. In: Jaeckel A, Telemedizin Führer 2001: Deutsches Medizin Forum; 2000.